These were the words spoken to me when I was a medical student doing an elective rotation in maternal fetal medicine at Mt. Sinai hospital in Toronto in 1997. Setting aside your surprise that I once wanted to be an Obstetrician (yes it’s true), I should put in context the situation that I heard this career changing advice. The service I was on was intense. Intense in the sense that some of the attendings were quite demanding and in their endless pursuit of excellence in care demanded a great deal from the medical students, residents and fellows around them. While I don’t remember the name of the fellow I was working with any longer, I do recall the verbal abuse she took on a daily basis likely from some misguided notion that since the attending had to endure such humiliation during training others should have to experience such joy themselves. After one such encounter, I had the opportunity to go for a coffee with my fellow and I took the opportunity to learn her coping mechanisms.

“Kill Them With Kindness”

You see this was no ordinary fellow. No matter how much verbal abuse was hurled her way she smiled at the attending and asked what she could do to resolve whatever shortcoming was pointed out to her. She never seemed upset (although on the inside I can’t imagine how she couldn’t) but kept her composure. When I asked her how she endured the daily grind all she said were those four words. I was very curious about this strategy. It seemed to me that she was enabling such behaviour and quite honestly in this era of medicine I have my doubts that the attending could get away with it. Having said that while it might not be so dramatic these days, it does happen but to a lesser degree. She explained to me that she believed that when you are consistently nice to someone even in the face of aggression they have no choice but to settle down. As she put it, staying angry in the face of someone who is smiling and thanking you sincerely for your input is difficult even for the most aggressive types. I suppose it is similar to a someone who is teasing you, stopping when they see they can’t get a rise out of you. I really took what she said to heart and built my career around this principle.

The Power of the Word Please

A funny thing happened today which really is what triggered this memory for me. One of our nurses chose to write a verbal order for me. She started the verbal order off with “please”. When I saw the start of the order I laughed and said that is the way I would have written it and she told me she knew as that is how I usually start my orders! It is sincere and not meant to be a trick but I think I owe it in part to that fellow from many years ago who taught me to “kill them with kindness”. My use of the word please which I realize now I use more often than not might seem odd but I think it sends a message of respect. An order should be followed but perhaps the word please is a way of saying “I realize you are busy but if you could do this I would appreciate it!” In the end we are a team and putting a little niceness into our daily routine can go a long way.

No Place For Rudeness

In a RCT designed to measure the impact of rudeness, medical teams were given a case to manage in a simulation exercise. The case was of a preterm infant now 23 days old with symptoms of NEC. Half the group met with a visitor who claimed to have observed such teams in their country before and in the rude environment made a disparaging comment about the past performance of the other teams. In the other group he simply mentioned he had observed other teams without commenting about their lack of skill. Simply planting the seed that previous performance of a similar team had been poor had damaging effects on team performance as shown below. Each item was rated from 1 = fail to 5 = excellent.

As you can see on many domains, team performance was impacted and in a significant way. Imagine how powerful more overt rudeness can be and damaging to the confidence and performance of the trainees and teams around you!

Let’s Get It Right

It’s July and that means there is a new crop of residents and fellows starting their journey towards becoming independent practitioners. This isn’t simulation anymore, this is the big leagues and they are working on real patients at risk of real adverse outcomes. Imagine if you will if the performance in the simulation above translated into poor performance in the hospital! We do our best to teach these “green” trainees the right way to do things but no amount of information will do them any good if we kill their confidence. Life as a new trainee is stressful enough. Can’t we all do a little to make things just a bit easier?

Yes it can be frustrating when they miss something important and yes that can have a consequence to patient care but if we want to minimize the greater risk to the patient population couldn’t we all do a little more to “Kill them with kindness” and say “please” from time to time?